Provider Demographics
NPI:1891171138
Name:RENEE WALL, DDS, PA
Entity Type:Organization
Organization Name:RENEE WALL, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-362-1394
Mailing Address - Street 1:100 HYANNIS DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-8327
Mailing Address - Country:US
Mailing Address - Phone:919-362-1394
Mailing Address - Fax:
Practice Address - Street 1:100 HYANNIS DR
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-8327
Practice Address - Country:US
Practice Address - Phone:919-362-1394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RENEE WALL, DDS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC67321223G0001X
NC93281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC811370OtherUNITED CONCORDIA
NC9008POtherBCBS